Does Medicare Cover Adult Day Care?
Discover if Medicare covers adult day care services and explore alternative funding options for your loved one's care needs.
Adult day care programs provide supervised care, social activities, meals, and sometimes health services for adults during the day. While these centers offer valuable support, Original Medicare generally does not cover them, especially services focused on custodial or social care.
Medicare’s Approach to Long-Term Care
Medicare is a federal health insurance program primarily designed for acute medical needs rather than long-term care. It distinguishes between medical care, which addresses illnesses or injuries, and custodial care, which involves assistance with routine daily activities. Original Medicare (Parts A and B) typically covers hospital stays, doctor visits, and medically necessary skilled nursing facility stays or home health care for a limited period after an illness or injury.
Medicare Part A, known as hospital insurance, helps cover inpatient care in hospitals and limited stays in skilled nursing facilities following a qualifying hospital stay. This coverage for skilled nursing facilities is generally limited to 100 days per benefit period, with a daily coinsurance payment required after the first 20 days. Medicare Part B, or medical insurance, assists with medically necessary doctors’ services, outpatient care, and some home health services.
Long-term care focuses on assisting individuals with activities of daily living (ADLs) like bathing, dressing, eating, or supervision. These are common components of adult day care. Medicare typically does not cover these services when they are the primary need, as they are considered non-medical or custodial.
Original Medicare and Adult Day Care Coverage
Original Medicare (Parts A and B) generally does not cover the comprehensive services of adult day care centers, including social activities, meals, and general supervision. Its focus remains on medically necessary treatments and skilled care.
Original Medicare might cover specific components of adult day care if medically necessary. This includes skilled nursing care or therapy services like physical, occupational, or speech-language pathology, if delivered by a Medicare-certified provider with a doctor’s order. Specific mental health treatments offered through an adult day care center may also receive coverage.
An exception to the general lack of coverage is the Program of All-Inclusive Care for the Elderly (PACE). PACE is a comprehensive program that coordinates and provides all healthcare services an older adult needs, including adult day care, to help them remain in their community. However, PACE is not available everywhere and has specific eligibility requirements, such as being at least 55 years old, living in a PACE organization’s service area, and requiring a nursing home level of care while being able to live safely in the community with PACE’s support.
Medicare Advantage Plans and Adult Day Care
Medicare Advantage (Part C) plans offer an alternative to Original Medicare, provided by private insurance companies approved by Medicare. These plans must provide all the benefits covered by Original Medicare (Parts A and B) and often include additional benefits not covered by Original Medicare. Such additional benefits can include dental, vision, hearing, and fitness memberships.
Some Medicare Advantage plans may offer supplemental benefits, including adult day care days or related services. This is not a universal offering, and availability varies by plan, provider, and geographic location. The decision to include adult day care benefits rests with the private insurance company.
Individuals considering a Medicare Advantage plan should carefully review the plan’s specific documents, such as the Evidence of Coverage. It is advisable to contact the plan provider directly or consult with an insurance broker to determine if a particular Medicare Advantage plan includes adult day care benefits. This direct inquiry ensures clarity regarding coverage details, limitations, and any potential out-of-pocket costs.
Other Funding Options for Adult Day Care
Given the limited coverage by Medicare, several alternative funding options exist for adult day care services. One significant source is Medicaid, a joint federal and state program designed for low-income individuals and families. Medicaid often covers adult day care for eligible individuals, primarily through Home and Community-Based Services (HCBS) waivers. These waivers help individuals receive care in their homes and communities, serving as an alternative to institutional care like nursing homes. Eligibility criteria and the scope of covered services for Medicaid and its waivers can vary by state.
The U.S. Department of Veterans Affairs (VA) also provides coverage for adult day health care for eligible veterans. Programs such as the VA Health Care System and the Aid and Attendance benefit can help veterans access these services. Eligibility depends on factors like service history, health needs, and financial situation, with a clinical assessment often required to determine the need for care.
Private long-term care insurance policies are another avenue for covering adult day care costs. These policies are specifically designed to pay for long-term care services, including adult day care, depending on the terms and benefits outlined in the individual policy. Coverage often becomes available when the policyholder needs assistance with a certain number of ADLs.
Many families also pay for adult day care services directly out of pocket. The national average cost for adult day care was approximately $95 per day in 2023, though daily rates can range from $50 to $150 or more, depending on location and the specific services offered. Additionally, some states or local communities may offer non-Medicaid programs or grants that provide financial assistance for adult day care.